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How to Establish an Evidence-Based Care Delivery Structure Like Allina Health
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Transcript of How to Establish an Evidence-Based Care Delivery Structure Like Allina Health
© 2015 Health Catalyst
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How to Establish an Evidence-Based Care Delivery Structure Like Allina HealthWebinar, April 27, 2016
Dr. Timothy Sielaff
Anna Kleckner, MPH, PhD
CMO & SVP Specialty Care and Research
Evidence-Based Practice Consultant
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Learning Objectives
1. Identify necessary components in a system-wide evidence-based decision-making model
2. Understand how to provide consistent, optimal care to patients regardless of treatment location
3. Leverage existing data sources to monitor adherence to clinical practice guidelines
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Jane’s Story
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Screen
Dx mammo+ 1/2 day work
Bx+ full day work
PET
Lung Bx & Ptx+ (1 HD)
Pos margin lumpectomy
Re-excision
Oncotype Dx
Chemotherapy
Jane’s Story
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a) Yes – 7%
b) No – 45%
c) Both – 41%
d) Nei ther – 6%
Poll Question
Did Jane get great care? 82 respondents
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6
90+ clinics
13 Hospitals
16 Pharmacies
Allina Health
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Allina Health plus …
11 regional health systems
2,900 physicians
over 60 practices
24 specialties
13 EMRs
non-exclusive to Allina Health
Allina Integrated Medical Network
8
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One promise
Shared clinical imperatives
Best practices
Variation in care
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Clinical Service Lines (CSLs) –Program Committees
Onc
Neurosci
CV
Breast, Lung, GI (Colo., Upper, HPB), Gyn Onc
Heart Failure, Structural, Prevention
Epilepsy, NeuroVasc (stroke, IR, telestroke), NeuroOnc
+ 8
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Uncertainty and Variation in Healthcare
difficult decisions & uncertainty
variation & waste1,2
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1. Han PK, Klein WM and Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decision Making
November/December 2011 31: 828-838.
2. Delaune J and Everett W. Waste and Uncertainty in the U.S. Health Care System. New England Healthcare Institute. 2008.
Available at: http://www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf
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Capturing Opportunities
12
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
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Clinical practice guidelines
(CPGs)
Incorporating Evidence into Care
• Best available evidence
• Decision making
• Care delivery
13
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
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“Systematic, evidence-based process
improvement methods applied in various
sectors to achieve often striking results in
safety, quality, reliability, and value can be
similarly transformative for health care.”
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
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Evidence-Based Decision Making (EBDM)
Best available evidence
Clinician's expertise
Patient's values & preferences
Shared decision making
15
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM (2nd
edition). Edinburgh & New York: Churchill Livingstone, 2000.
Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. Shared Decision Making to Improve Care and Reduce Costs. N Engl J Med
2013; 368:6-8.
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EBDM Challenges at Allina
• Variation in processes for developing CPGs
• No standard framework
• Providers are busy
• No system-wide policy or infrastructure
16
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Poll Question
Does your organization have standard process for development of
system-wide best practices? 90 respondents
A) None or not sure – 16%
B) Just getting started – 24%
C) Half-way there – 30%
D) Well-established (I should be giving this webinar) – 3%
E) Not applicable – 27%
17
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How Allina Built the EBDM Infrastructure
1. Implemented a System-Wide EBDM Policy
2. Established EBDM Governance
3. Tested Feasibility & Utility
Stage I Lung Cancer
IV Heparin
4. Prioritization Criteria
5. Culture of Collaboration
18
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1. Implement a System-Wide EBDM Policy
Language
Terminology
EBDM Framework
Checklist
19
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Language
Purpose Statement
• Improve care delivery and patient satisfaction
• To reduce variation in standards of practice across the system
• To standardize operational processes in guideline development
• Reduce costs
20
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Language
Policy Statements
A. “Allina Health will follow a standard process for the development,
approval, revision, and implementation of Allina Health clinical
guidelines for specific clinical circumstances.
B. …ensure compliance with the processes and procedures within
the Allina Health Model for Evidence-Based Decision Making …”
21
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Language
Expectations for Physicians
• Follow approved guidelines
• “Deviations” expected
• Documentation of deviations expected
22
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Terminology
Policy
A comprehensive statement developed to assure appropriate
action or work is performed and is in compliance with applicable
regulation or law.
In general, policies define “what we do” and remain fairly
constant over time.
A policy:
● communicates what must be done and the desired
outcome of that action
● provides principles to guide decision making
23
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Terminology
Clinical Guideline
• Systematically developed statements designed to support the decision-making processes in
patient care
• Intended to optimize patient care and are informed by a systematic review of evidence and an
assessment of the benefits and harms of alternative care options
• Identify and evaluate the most current information about prevention, diagnosis, prognosis,
therapy, risk/benefit and cost effectiveness
24
Allina Health Clinical Guidelines have been, or are being, submitted
for approval through the Allina Health Quality Council, and may include
adoption of existing national clinical guidelines, or expert-driven
statements that meet the definition of System-Wide Clinical Guidelines.
• Different from policies, guidelines define and guide not what we do,
but why and how we do it.
• Expected to change along with evidence, and should be reviewed on
a regular basis.
EBDM Framework Allina Health Model for EBDM
Variation/ Gaps/ Inequities/QI opportunity
Synthesize Knowledge
Formalize Knowledge
Localize Knowledge
Implementation
& Evaluation
Process
Development
Process
Stakeholder
Review Process (Policy, Procedure, Guideline, Other)
Measureable Impact
Allina Information• Data Analytics• Critical Events
• PICO(TS) Framework
• Content Review
• Experts, Literature, Patients
• Library Services
• EBP Methodologist
• Project Management
• Stakeholder Review
• Strategic Alignment
• Quality Review
• CDS, Excellian
• Education
• Compliance
• Diffusion
• Analytics
• Research
Allina Health Resources
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Checklist
26
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2. EBDM Governance
• Endorsement body (monthly)
Policy experts endorse processes & format
• Peer review & approval body (monthly)
Quality experts (medical & executive)
• Tracking system
3-year (max) review cycle
• EBDM Core Team (quarterly)
Diverse group, customer voice
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Stage I Lung Cancer IV Heparin
3. Proof of Feasibility & Utility
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Stage I Lung Cancer Opportunities
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• Establish consensus
• Allina Health “best practice”• NCCN, ACCP guideline
• High risk definition
• Monitoring & feedback
Site A B C
TreatmentSurgery
(%)
RT
(%)
Surgery
(%)
RT
(%)
Surgery
(%)
RT
(%)
Pre (N = 324) 69 31 81 19 96 4
Post (N = 100) 85 15 63 37 85 15
Difference by
Site+16 -16 -18 +18 -11 +11
Variation in treatment was 27% (surgery: 96% - 69%, RT: 31% - 4%)
Variation in treatment was 22% (surgery: 85% -63%, RT: 37% - 15%)
5% reduction in variation across the system
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Stage I Lung Cancer: EBDM Model
30
Variation/ Gaps/ Inequities/QI opportunity
Synthesize Knowledge
Formalize Knowledge
Localize Knowledge
Implementation
& Evaluation
Process
Development
Process
Stakeholder
Review
Process
(Policy, Procedure, Guideline,
Other)
Measureable Impact
Allina Information• Data Analytics• Critical Events
• PICO(TS) Framework
• Content Review
• Experts, Literature, Patients
• Library Services
• EBP Methodologist
• Project Management
• Stakeholder Review
• Strategic Alignment
• Quality Review
• CDS, Excellian
• Education
• Compliance
• Diffusion
• Analytics
• Research
Allina Health Resources
• PICO Lit Search
• PICO Lit Review
• Analytics
• Newsletters, Intranet
• Analytics
• NCCN abstract/poster
• Charter
• Adopt Guidelines
• Committee Approval
• Quality Council
approval
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IV Heparin Opportunities
• Standardization of IV Heparin
• Improve patient safety and patient experience
• Reduce costs:
• Use APTT instead of anti-Xa
• Adverse events, especially bleeding
• Improve safety monitoring of anticoagulation meds (Joint
Commission National Patient Safety Goals)
Pre: 20+ site-based documents (policies, protocols, etc.)
Post: 1 system-wide guideline, 4 system-wide protocols
31
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IV Heparin: EBDM ModelVariation/ Gaps/ Inequities/QI
opportunity
Synthesize Knowledge
Formalize Knowledge
Localize Knowledge
Implementation
& Evaluation
Process
Development
Process
Stakeholder
Review
Process
(Policy, Procedure, Guideline,
Other)
Measureable Impact
Allina Information• Data Analytics• Critical Events
• PICO(TS) Framework
• Content Review
• Experts, Literature, Patients
• Library Services
• EBP Methodologist
• Project Management
• Stakeholder Review
• Strategic Alignment
• Quality Review
• CDS, Excellian
• Education
• Compliance
• Diffusion
• Analytics
• Research
Allina Health Resources
• PICO Lit Search
• PICO Lit Review
• Formulation of Work
Groups
• Charter/Aim
Statement
• Recommend aPTT
• 1 guideline, 4
protocols
• Screening tool
• Benchmarking
• Onsite visits
• Excellian
• Dashboard
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Anticoagulation Safety Dashboard
33
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Poll Question
How effective is your organization at implementing a new system-
wide best practice? 72 respondents
A) Not effective at all – 10%
B) Some better than others, depends – 44%
C) Effective, with some room to grow – 18%
D) Very effective (we should be doing a webinar) – 3%
E) Don’t know or Not applicable – 26%
34
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Development Implementation & Diffusion
4. Prioritizing EBDM Initiatives
Identified variation
Volume
Readiness
Alignment
Motivation
Champion
Impact a commonly performed
process
Implementation capacity
Operations support
Clinical leadership support
obtained
Champion
35
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5. Culture of Collaboration
• Collaborative vs. Punitive
Offering a service vs. requirement
• Clinical Service Line / Program Structure
• Start with low-hanging fruit
Gained momentum
Reduced skepticism
• Dedicated resource (1 FTE)
36
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What’s Next?
• Expand policy and EBDM model to additional clinical areas and
conditions
- 20 approved guidelines in 1 year
• Upstream implementation consult
- Resource identification
• Implementation, measurement & communication of guideline
initiatives
- Evidence-Based Care Delivery Dashboard
37
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The Cost of Jane’s Story
Screen
Dx mammo+ 1/2 day work
Bx+ full day work
PET
Lung Bx & Ptx+ (1 Hosp d)
Pos margin lumpectomy
Re-excision
Oncotype Dx
Chemotherapy
$500
$1000
$2,500
$4,500
$3,500
$5,000
$3,000
$3,000
$12,500
$37,000
Lost job …
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Waste
Screen
Dx mammo
Bx
PET
Lung Bx & Ptx+ (1 Hosp d)
Pos margin lumpectomy
Re-excision
Oncotype Dx
Chemotherapy
$500
$750 + $250 ½ day work
$2,000 + $500 full day work
$4,500
$3,000 + $500 + (1 Hosp day)
$5,000
$5,000
$3,000
$12,500
$8,500
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Q & A